Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Monday, December 24, 2012

No, Virginia, There Isn't Any Santa Claus


Dear Virginia—

No, of course there isn’t any Santa Claus! I’m surprised at you, a big girl like you asking such a question. How could you believe a story like that?

Oh, you say your parents told you about Santa Claus? And they say it’s wrong to lie, so you don’t think they’re lying? Even though sometimes it’s okay for grown-ups to do things that are not all right for kids?

Well, Virginia, this time they are definitely telling a whopper. It’s pretty shocking to realize it. But I think I can explain why they’re doing it, and if you could understand this, you would forgive them.

The thing is, your parents love you and want to protect you--  not just from disappointment and skinned knees, but from understanding how horrible the world can really be. Your parents and most other grown-ups have an ability called empathy, and when they learn about awful things they can imagine what it would be like for them--  and especially, for you—to have to experience them. Your parents have heard about Auschwitz, My Lai, Abu Ghraib, and the events in Aurora and Newtown. When they think of those things they are sometimes tormented by pity, terror, and helplessness. They don’t want you to be tormented like that ever--  but they know that’s not possible, so at least they want you to feel happy about the world until you’re a lot older. They try to protect and defend you against terrible knowledge, and to do this they often do their best to fill in the gaps with stories of magical beauty, goodness, and happiness. They want to keep you as long as they can without the knowledge of evil that intrudes into every adult’s holiday, the fear of death that attends the birthday party, the ghost of loss that dances at every wedding. They summon Santa Claus to ward off those threats, and for some years he may do the job for their special children.

But you’re moving past that stage of life, Virginia. You want to know more of the things that adults know, even though you’re far from ready to know it all. (Indeed, who is?) What can you learn from the discovery that Santa Claus is not real?

Let’s start with learning to question anecdotes and testimonials, whether they’re on the Internet, on NPR, or from Mom and Dad. Trust, but verify, right? That’s the best policy if you really want to know what’s going on. On the other hand don’t forget that people, even you, don’t always really want to know. You can learn from the Santa Claus story that sometimes we like to work our own magic, tell ourselves lovely tales, and keep away the bad fairies that hover around our pillows all our lives. There’s nothing wrong with that as long as we don’t tell ourselves stories that encourage us to hurt other people or take away things they need, stories that convince us that we’re more important than anybody else.

You can also learn from this discovery that human beings are often willing to do things that are wrong in order to protect those they care most about. Your parents say it’s wrong to lie, and they believe it, but they will do that and much worse if they think it’s good for you. I’m not saying not to trust them--  but from now on you may want to give some thought to everything anybody tells you, before you make it your own belief. If you can manage that, you will have learned a lot.

I’ll bet that your parents would forgive you a lie if they understood that you told it because you were scared. It may be hard for you to believe, but they sometimes lie about things because they’re scared too. Learn this, and you’ll know that the Santa Claus story was not just told to fool you.  It made you feel good for a while--- and that made your parents feel good too. Now that you’re older, you and your parents will need to find new ways to handle the fears that we all have.

Best love,
Jean

P.S. There’s no need to break this important news to your little brother. Besides, believers always get mad when you try to reason with them.


Tuesday, December 18, 2012

Professional Parent Alienation Syndrome: Heads I Win, Tails You Lose


More news about Eve Innocenti, whose Kafka-esque case was discussed on this blog a few days ago. Eve was present by telephone at a meeting with social workers to discuss her being allowed to have contact with her children, who are now with their father and stepmother except when they are in residential treatment or a therapeutic foster home supervised by the attachment therapist we referred to as Woodrow Thynne.

Here’s what Eve was told: she may not have contact with the children unless she states that she abused and neglected them when they were in her care. Her refusal to “take responsibility” by dropping her denials of these accusations is interpreted as symptomatic of an ongoing emotional disturbance. As long as she denies guilt, say the social workers, she cannot help her children “heal” from the impact of what she is said to have done.

What is she accused of doing? Here’s an interesting thing: in a further Kafka touch, no one will tell her. She has been told that what she must do is to make a written list of bad things she did to the children, and the social workers will check it against what the children say. However, the children’s guardian ad litem has told Eve that in fact the accusations are related to information in letters from the children’s schools a year after they went to live with father and stepmother--  and these were not the same schools they attended when living with Eve.

Did the unspecified allegations then come from the interpretations teachers placed on things the children said, spontaneously or perhaps not so spontaneously? Maybe--  but let’s not forget that one of the techniques of attachment therapy can be to have children repeat over and over words given to them by the therapist, stating their hatred for a past caregiver and describing the awful things she did. This is considered to be expressing emotion, but can easily be a matter of putting words in a child’s mouth. Statements by children that were clearly guided or suggested by a questioner are not admissible in court, and in fact court-related interviews with children about their experiences are videotaped to show whether suggestions were given. A therapist may not appear in court, and if he or she does appear, a videotape of the therapy session is not usually requested. Certainly the alleged letters from the schools did not include videotaped evidence of the children’s statements.

It’s understandable that decisions regarding children should be made in a more private manner and with fewer procedural constraints than are found in a criminal court. Either adult or child behaviors may not reach a criminal level, but may show the need for some type of protection of the child that will prevent worse from happening. But have we not seen enough abuses of this special kind of court proceeding? A year or two ago, we had  juvenile court judges of Luzerne County, PA  sending children to prison-like residential situations and receiving financial kickbacks from the operators. This morning’s New York Times discusses reform of the Shelby County, Tennessee system that has mistreated juveniles for many years.

The particular abuse that Eve is experiencing—refusal of information and treatment of her denial as if it were an especially serious form of confession—is one that has also been experienced by fathers falsely accused of sexual abuse of their children. It could not happen when adults are tried in a civil or criminal court, but it is far from unknown in juvenile proceedings, and is largely connected with one tradition in U.S. social work. This tradition goes back to the days of the “psychiatric social worker”, and follows an intensely psychodynamic pattern of interpretation in which either confession or denial can be taken to mean guilt and in which actions can be attributed to repressed impulses; it does not, however, seem to include the possibility of false confessions resulting from persuasion. The tradition also interprets denial of accusations as evidence that an emotional disturbance not only existed in the past, but still exists, and will have deleterious effects on the children if any contact is allowed.

This tradition has the capacity to wreck lives and to violate the civil rights of both parents and children. It is ironic but unsurprising that practitioners who believe that loss of attachment figures is a primary cause of mental illness feel that such a loss, when engineered by the therapists themselves, is to the benefit of the children. It is also unsurprising that the therapists interpret the distress of a mother who has effectively lost her children as evidence of mental illness and as a reason why she should be denied contact. When we mingle the psychodynamic social work tradition with attachment therapy, as well, we need not be surprised at the circularity of reasoning that states that children who have been diagnosed with a form of attachment disorder must by definition have been abused or neglected, and that the diagnosis itself is evidence that a caregiver has done wrong.

There has been a lot of discussion in recent years of the so-called “Parental Alienation Syndrome”, a behavior pattern in which one member of a divorcing couple accuses the other of abuse, both publicly and in direct communication with the children. The goal is to destroy the children’s regard for the accused parent and to maximize the accuser’s custodial power. This behavior does exist, of course, although it is probably a mistake to call it a “syndrome” and thus imply that it is a useful diagnostic category of mental illness. In Eve’s case, however, we seem to be seeing a new version of parental alienation, performed by professionals as they exercise what Oscar Wilde called “officialism”. The social workers, the therapist Woodrow Thynne, court functionaries, and others have dedicated themselves to alienation of a parent and destruction of her children’s regard for her. Strangely, it seems that efforts to work with and support a parent who had been genuinely abusive would be pursued with energy, while the opposite is being done in this case--  the energy is devoted to alienation.   


Thursday, December 13, 2012

The Attachment Therapist Wears Two Hats, or, Kafka in Colorado



In Franz Kafka’s novel The Trial, the central character, Josef K., is mysteriously accused, tried, convicted, and sentenced for a crime that is never named and by a court that is never seen. Agents of the court try to make the condemned Josef K. kill himself, he refuses—and they carry out the sentence.

Couldn’t happen at all? Couldn’t happen here? Couldn’t happen to anyone like you? I’d like to be able to agree with those statements, but I have a story to tell that has convinced me that Franz Kafka is writing scripts for Colorado courts.

Here is the basic story, with all names changed. (I have permission to use the central person’s name, but I think it may be more prudent not to do so.)

Eve Innocenti was a young Colorado woman with a rough family background who was trying to get on her feet. In her early 20s, she had a baby with a young man with a drug problem—call him Fred—and was awarded full custody of that baby. A second child  with a different father followed a few years later, and Eve also had full custody of that child.. Meanwhile, Fred married Wilma and had another baby with her. Eve’s children visited Fred and Wilma periodically and the co-parenting went well. When Eve needed to be away for a couple of weeks, she asked Fred and Wilma to care for her boys. On her return, however, she was not able to get the children back from Fred and Wilma.

Eve went to court to ask for the boys to be returned to her custody and continued to make this request, with occasional visits from the children, over several years. But Fred was given full custody of both boys, his own son and the second child to whom he was unrelated. Eve was denied contact with either child, and a legal staffer even suggested that a restraining order might be appropriate because Eve walked out of the hearing.

Eve then married a man in the military and the couple moved to a nearby state, from which Eve tried to continue her efforts. She was allowed to drive 8 hours from the neighboring state once each week, to see the children for one hour.  Soon, however, the visits are ordered stopped for a period of a year. Shortly after that time period, the Colorado county filed a Dependency and Neglect case that could ensure that Eve does not have visitation with the boys--- even though Fred and Wilma had separated and Wilma had custody of the children. (Fred later returned.)

This brings the story up to a few months before the present day (Dec. 13, 2012). At that point, some interesting and disturbing new facts began to emerge. Wilma, it seems, had sought the help of an attachment therapist, one Woodrow Thynne, I’ll call him, who conducts an “institute” and residential treatment center in the vicinity of Long Green, CO (which I’m naming for its financial advantages to therapists). Wilma complained that the boys had symptoms of Reactive Attachment Disorder and were difficult to handle. The boys were treated in Thynne’s therapy program and at least one stayed in a “therapeutic foster home” connected with the center.

County legal and social work staff told Eve that Thynne’s report to the court would determine the custody of the children. Thynne was continuing to act as a therapist for Fred and Wilma’s family. If Thynne had been a psychologist, he would have been prevented by a professional ethical code from wearing both hats--  as therapist and as evaluator. As a social worker, however, he was only required to clarify his position with all family members. This should have included Eve, but in fact he had neither seen or spoken to her at any time. Eve’s appointed public defender, who should have been dealing with the situation, did not return her calls; Eve and her husband could no longer afford to hire a private attorney.

In mid-December, 2012, Eve managed to have a conference call with Woodrow Thynne and the guardian ad litem whose job it is to represent the children’s interests. Several interesting and disturbing points were  revealed during this conference. One was the fact that it was Thynne’s intention to break the attachment that the boys had to Eve, and to re-attach them to Wilma, following what appears to be a Velcro theory of emotional development.. A second was that Thynne believed that the children had been removed from Eve’s custody because of her neglect or abuse, and declared that he was not aware of the actual history (but nevertheless he did not immediately bring the process to a halt, as might have been expected). Third, Thynne referred, apparently without disapproval, to Wilma’s attempts to discipline the younger boy by threatening to send him to visit Eve; such a threat of abandonment would ordinarily be considered highly inappropriate for a child suffering from the effects of a complicated separation history. Finally, Thynne denied that his report would be the basis of the court’s custody decision, leaving open the question of the evaluation that would be used. But because it is part of Thynne’s technique to have children state that they were abused and neglected, his report will provide misinformation that cannot be contradicted by Eve.

In response to statements during the conference call, Eve began seriously to consider relinquishing custody of the children rather than continuing to fight against unknown charges in a process that has no predictable outcome except bankruptcy and court records that may be used against her in the future. She e-mailed her attorney about this and got an immediate answer telling her how to begin.
The likely result of all this is that a stepmother will receive custody of children whose birth mother not only wants them but has shown every evidence of caring for them well. The father of one child will have also have custody of another man’s child. Both children will continue to receive a treatment that has no evidence basis, supervised by a therapist who has apparently not troubled himself to understand the children’s family history.

Like Josef K., Eve has been accused of unstated crimes for which there is no evidence. Those who were supposed to help her have avoided her. Those who claim to be helping her children ignore the facts of the children’s lives and persist in beliefs and practices that have been rejected by organizations like the American Professional Society on Child Abuse. The information she needs has been withheld from her. Now she is offered the knife to stab herself in the form of relinquishment of custody, a step that is not only repugnant to her but predictably harmful to her own professional and personal options, as well as easy for the children to interpret as a final abandonment.

Surely Kafka is alive and well in Colorado and has written Eve and the children into a novel.

Monday, December 10, 2012

Toilet Training Concerns and Older Adoptive Children



 When I read blogs and Internet chat by adoptive parents who believe their children have some form of attachment disorder, I often see the expression of concern—and disgust—over toileting problems (for instance, see attachment.china.parenting.html). It is assumed that children over some certain age are capable of controlling bladder and bowels, that lapses are usually intentional attacks against adult caregivers, and that the child’s efforts to “hide the evidence” only show what liars and sneaks they are.

This set of beliefs is fostered by the continued circulation of a 1996 paper by Keith Reber (referred to on many adoption and attachment therapy sites, but I can’t find a URL for it at the moment). Reber, who incidentally later had his professional license revoked , stated in that paper that various physical acts like vomiting and defecation were intentional actions of children with Reactive Attachment Disorder and were expressions of rage about abandonment by the birth mother.   Regarding physical processes as intentional, of course, leads to the assumption that if the child wanted not to vomit, or urinate, or defecate, he or she would be able to inhibit these impulses. What follows as the day the night is often a plan to give the child good reason to control bodily functions by providing punishments, or, to use the language associated with attachment therapy, consequences.

Given that even healthy adults may urinate or defecate involuntarily, or be unable to do either at will, why would it be assumed that older children are always in control of elimination? There are various “psychological” (i.e., non-physical, non-biological) explanations that can be deployed to support this assumption--  although, as I’ll point out, there are reasons to doubt the applicability of each of them.

The first “psychological” explanation comes from common observations and interpretations of the behavior of pet animals. When their environments are disrupted and they are made anxious, cats and dogs sometimes urinate and defecate at unusual times and places. Pet owners and even some veterinarians interpret this behavior as an expression of anger or resentment toward the owner--  even though the animal’s general behavior displays anxiety rather than any anger cues like growling, hissing, or direct attack. The animal’s actions may be an attempt to find a place for elimination that resembles the usual setting, so for instance a cat inadvertently shut in a bedroom may defecate on a pillow rather than in the preferred but unavailable litter box. At other times, the behavior may be a form of displacement--  performing a normal behavior in an unusual situation, as when birds preen or humans yawn in response to anxiety. In none of these cases is the eliminative lapse due to anger, although they are commonly interpreted in that way. Thus, these animal situations are not a good foundation for assuming that children’s toileting problems are due to their anger.

A second problematic “psychological” explanation, the psychoanalytic concept of repression, may also lead parents to assume that children’s toileting problems are in a sense intentional. Repression is a speculative mechanism which is said to place unpleasant memories outside the reach of consciousness, and which allows those memories to motivate behaviors that may be quite undesirable. Such behaviors cannot be brought under control until the repressed memories are made conscious, but this is an uncomfortable process which the child resists. The belief in repression lacks empirical evidence but has become completely accepted in popular psychology, so “everybody knows” that this is how the human mind works. Parents are easily convinced that behavior that is a problem, and that they do not seem to be able to change, must be a direct result of children’s past traumas and a way for them to “act out” emotional concerns. This remains a common way of thinking about problems of elimination, and especially about relating such problems to sexual abuse, even though there is good evidence that people do not usually repress even very horrible memories (although they may suppress or try not to think about them). The lack of evidence for repression argues against the use of this concept to explain why some children have unusual toileting problems.

A third “psychological” explanation is one that frequently occurs in discussions of “attachment therapy” for adopted children. Proponents of this way of thinking hold that children who have been deprived of emotionally warm, nurturing care become frightened of emotional closeness and attempt to withdrawn when they feel themselves moving toward attachment relationships. Their fear, it is said, leads them to “sabotage” such relationships by behaving hatefully or disgustingly toward adult caregivers—and inappropriate urination and defecation are certainly effective ways to do this. Caregivers may complain that a child soils underwear or fails to wipe properly, or wets underpants and then hides them, and so on--  even though the child is apparently quite old enough for bowel and bladder control. The explanation given for these actions is that the child is afraid of getting close to someone and being disappointed, as an adult might be after experiencing several failed marriages.

How do we argue for or against this explanation? Children’s histories can be so complicated that it is very difficult to figure out why a behavior occurs. But is it plausible to claim that a child shows the behaviors just described, or similar ones, because they are trying to avoid the fearsome experience of emotional intimacy? Maybe examining an analogy will help out here. What happens when young children are deprived of food or underfed for a period of time? Would we expect such children to be frightened of food or to avoid situations where there are plenty of appetizing goodies? This seems most unlikely, and it is much more probable that such children will be preoccupied with food, hoard it, even steal it. Why then assume that lack of emotional warmth will make children afraid of attachment? And if there is no reason to think they are afraid of attachment, how can we attribute their behavior to such fear? The “attachment therapy” explanation of toileting problems thus seems as unacceptable as the other “psychological” approaches.

So, what do we have left? The common psychological explanations seem unsupported. In addition, it’s a good idea to keep in mind the rule of parsimony--  that if several possible explanations are offered, and no reason exists to choose any particular one, it is safest to go with the simplest explanation. Without implying that psychological explanations are never correct, the principle of parsimony suggests that non-psychological, physiological explanations may be the best approach to some problems of behavior, especially those with strong biological components, like elimination.

I want to offer some possible physiological explanations for the toileting problems reported by some adoptive parents. (I’ll provide some sources for this information at the end of this post.) First, let me mention bedwetting. Unless a child is frightened to get up for some reason, bedwetting occurs during sleep, is not under conscious control, and is not very responsive to daytime training methods. About 75% of boys, and quite a few girls, are not reliably dry at night until age 5, and some individuals go on for years wetting at night in spite of their own and everyone else’s best efforts. The developmental  step of staying dry at night is largely under genetic control, whereas the steps in successful daytime control are much more responsive to the child’s experiences. However distressing and annoying it may be to have a large child wet the bed, the problem is not likely to be solved by punishments, rewards, or psychotherapy either conventional or unconventional.

Daytime bowel and bladder control is responsive to training. However, in the cases of adopted or foster children, the child and the caregiver may have to deal with the results of training efforts and experiences that occurred long before the present placement. For example, the child may have had to hold urine so long that the bladder muscles have become insensitive to the pressure of a full bladder. The child does not urinate often, and as a result may develop urinary tract infections or experience leaks that do not empty the bladder completely (hence, perhaps, those moist panties that are hidden somewhere until the smell reveals them). Having to wait to move the bowels--  or fear of a painful bowel movement--  can create a similar situation in the colon. In that case, softer stools may leak around the hard stool retained in the colon, staining underwear and creating confusing sensations which the child cannot trust as an indication that it’s time to go to the toilet.

If the adopted child has already developed these problems, it may be necessary to see a urologist and/or a gastroenterologist in order to understand and work with the physiological causes of the difficulty. This should be presented as help, not as punishment, because the child is in fact not intentionally behaving inappropriately. Drinking a lot of water (not carbonated beverages, fruit juices, or caffeinated drinks) and using a timer as a reminder of the time to urinate can help retrain a bladder that has become insensitive. Water is also helpful for constipation, and so are food with plenty of fiber and a lot of exercise (children with physical disabilities may need professional help in the area of exercise).

What if a child develops bowel and bladder problems after adoption? I would suggest thinking over carefully whether certain precepts of popular attachment therapy are being followed. For example, is the parent convinced that the child must go through a period of complete dependency in order to mature emotionally? Those who are advocates of this belief may require that the child ask for everything that is needed, whether a drink of water or the use of the toilet, and do nothing without permission from the adoptive parent. This is oftenenforced by placing an alarm on the child’s bedroom door or locking the door. Children may be severely punished by “paradoxical interventions” such as forced drinking if they have taken a drink without asking (one child died of hyponatremia as a result of this tactic). Children may also have “consequences” like limitation of food to peanut butter sandwiches. Limited water intake, limited and low-fiber food, and constraints on toilet use--  can you tell me a better way to cause eliminative dysfunctions? Where these practices are in use, I submit that there is no need to seek a “psychological” explanation of toileting difficulties.


Some sources:
Presentation by Dr.Christine Kodman-Jones for Delaware Valley Group of the World Association for Infant Mental Health, Dec. 7, 2012.

[By the way, if you came to this post looking for more general information about toilet-training, you might want to try http://dvgwaimh.blogspot.com/2012/12/a-relational-approach-to-toilet.html .]
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